Wednesday, September 29, 2010

I feel for 'em, I really do. They've spent time over at County General before coming to Sunnydale, and the doin's at County are both much more severe and much more boring than the ones here in the Hellmouth. Whereas at County you might see fourteen TBIs a day in the trauma unit, at Sunnydale, you'll see two cases of God Only Knows What. Both of the GOKWs seem stable, but in reality, they're just as prone to crump as the donor-cycle riders next door.

It's an adjustment--for me and for them.

Case in point: I had a patient this week who came in fine and dandy, stable as the rock of Gibraltar, and then (about six hours after admission) began to decompensate in a truly spectacular way. Now, keep in mind that my CCU, being mostly neuro and not post-surgical, doesn't have a lot of the Machines That Go Beep ready to hand. Therefore, when somebody who was breathing twelve times a minute begins to breathe twenty, your Spidey-sense starts to tingle. When that respiratory rate goes up to thirty, your hair catches fire.

When it's up to forty, with the patient retracting all the accessory muscles they have, you intubate. End of story. Never mind about the urine (they're not making any) or the blood pressure (systolic palp; no reading on the machine) or the change in neuro status: it's the airway that I'm primarily concerned about, and this dude didn't really have one. As in, his ABG showed a CO2 in the 90's and a normal bicarb. (Note for non-medicals: that means you're suffocating in your own carbon dioxide, and your body hasn't started to fix the problem.)

It wasn't really his airway that was compromised, to be honest: he simply didn't have any muscular strength below his neck. Damned if I know what his problem will turn out to be; all I know is that he's no longer *my* problem, because the kindly anesthesiology guy came and intubated him and took him away to MSCCU.

Before this, of course, came the Dance of the Uninitiated Resident. Other Jo and I paged, and got no response, and paged again, 911 this time, only to have the resident call back in response to the first page. At which point I cheerily informed him that we were intubating his patient right then, with the cart at the bedside. He came rushing up (I will say this for this new class: they're much fitter physically than the last one. He ran all the way from County and wasn't even breathing hard.) and insisted that we assess the guy's respiratory effort before sticking a tube down his throat.

Other Jo and I looked at each other, looked at the anesthesiology resident, and said in unison, "Tube him." Then Jo handed him a bougie and I continued to insert the foley/start additional IVs/etcetera.

After we got Not-Breathing Man down on a vent, the resident protested the intubation. "He was fine when he came in, and he was fine when I saw him two hours ago! Don't you guys think you were a little hasty?"

Other Jo and I looked at each other, looked at the resident, and said in unison, "No."

Because, you see, shit happens with people who look stable as rocks. Neuromuscular disorders can rob you of your sight, your hearing, your ability to move or breathe in as much time as it takes to type up a post on your fantastically popular nursing blog. The tricky thing is that they look perfectly healthy--unlike the patient in Trauma Bay Six who has half her head gone.

It's a learning curve. I don't get annoyed with the residents; I'm still on the left side of a very steep learning curve myself. Honestly, if I hadn't been aware that the guy in the bed had something that was acting like Guillain-Barre, I wouldn't have been on guard for respiratory issues. And the only way that I *knew* he had something like GBS going on was that I had been able to assess him in a different way than the resident had. Every-hour assessments are much different than a one-time thing: a slight change in strength can clue you in to impending disaster. I wasn't a hero, I just had access to more data.

In any event, we all made up and are friends now. And I got one of the nicest compliments I've ever gotten from a doc: as the anesthesiologist was working away at something, I had to hand him a syringe of sterile saline. They come with screw caps. For some bizarre reason, I was able to summon the muscular control to hold four things in one hand and thumb the cap off of the syringe with my one free digit. The doc said, "You have good hands." How sweet is that?